Written evidence submitted by The British Orthopaedic Association (WBR0056)

The British Orthopaedic Association (BOA) is the Surgical Specialty Association for Trauma and Orthopaedics in the UK. We now have over 5,000 members worldwide, the majority based in the United Kingdom and Ireland. It is a pivotal organisation within the British surgical scene, representing some 40% of the total surgical workforce.

In our response we cover several discrete points under relevant subheadings.

Impact of the COVID surge on surgeons

While routine elective surgery ceased during the COVID surge, urgent and emergency surgery continued, often with reduced access to theatres. During this period there were significant challenges in terms of mental and physical pressures including:

• Working in full PPE which meant longer operations, increased difficulty in communication, more cumbersome/awkward to work.
• Longer down-time between operations and slower operations due to infection prevention measures meant slower throughput overall.
• At times and in some regions conditions very challenging with difficult decision making about scarce resources.
• Changes in working patterns, including some surgeons not operating for months and in some cases taking up roles on the ‘frontline’ for COVID, e.g. those who took part in ‘turning teams’ in intensive care.
• Some surgical teams had people who needed to shield and although they could still do some work from home, the fact they were unable to undertake operations resulted in reduced staffing levels (e.g. for rotas) and disruptions to teams and service delivery. In some cases a hospital might have a surgeon absent from a small subspecialty (e.g. hand surgery) and this significantly increased the pressure on the few remaining members of that team at what was already a difficult time for the reasons stated above.

Each surgeon will have been impacted differently, and it is important these challenges are recognised and that those involved are supported effectively.

Additionally, a large cause of stress within Trauma care (in particular) was the significant degradation of the urgent and emergency provision, before the situation on the ground locally necessitated this. Some units have reported not providing adequate operating capacity for urgent cases as resources had been diverted to deal with a COVID burden which did not exist at the time. For any future planning, consideration needs to be given to only reducing services when genuinely necessary, rather than having facilities standing idle “just in case”.

There have also been concerns about differences in guidelines provided by relevant bodies across the UK during this time. At the beginning of the pandemic, staff needed central guidance that could then be implemented locally. NHSE achieved this by collaborating with relevant stakeholders (including the BOA), which made implementation much more straightforward. Unfortunately we have found, as time passed, that central guidance has involved delays, lack of clarity and contradictions in further advice. This has resulted in a conflict between a ‘rational local response’ and a ‘postcode lottery’, exemplified by the significant delays in definitions of ‘aerosol generating procedures (AGPs)’. Delays meant that in England, services were lengthening operating times and encumbering theatre staff with PPE, whilst other devolved nations had moved forward with evidence that these protections were not necessary.

Continuing impacts of COVID-19 on workforce

Throughput in trauma theatres continues to be slower than pre-COVID, due to infection prevention measures, and therefore some of the workforce and resilience issues arising during the COVID surge still persist, although not at such critical levels.

For elective operating there are very major concerns about the workload going forward; tackling the extensive backlog will be challenging. Prior to COVID, surgeons and surgical teams had been, at times, doing extra lists (under ‘waiting list initiatives’) but even with these the number of procedures performed had not been keeping up with demand, and the waiting list had been growing overall in the lead up to COVID. The waiting list has now ballooned due to the pause on elective operating during COVID, and there is a huge backlog. Some productivity gains may be possible, but to do so significant resources will be needed. There is an expectation that the NHS will be able to catch up, but careful planning is needed to ensure correct staffing across the whole pathway (surgeons, theatre team, rehab staff).

Training in the COVID-era and the future workforce

There is a concern in T&O about the training pipeline. Training in surgical specialties requires a trainee to complete specific numbers of certain procedures, which has naturally been more difficult to achieve during the pandemic. As an example, trauma operating was adapted to be undertaken by consultants in order to save precious theatre and anaesthetic time. Huge opportunities to allow trainees to benefit from NHS patients being treated in the private sector have been also been lost, despite these cases being managed as NHS patients by NHS consultants. This large scale disruption of training causes stress for trainees.

As a result of this disruption, a proportion of the trainees coming through the system will need extra time for their training and this will slow the progress of those coming through. The numbers of trainees has generally been calculated to ensure that there are enough to meet the demand as they qualify. However, if significant numbers take longer than expected this could put pressure on the existing workforce, or means more gaps in rotas requiring locums. In our view, this is an issue that isn’t likely to have an immediate impact, but potentially a year or two down the line we might start to see the numbers that complete training is less than it would have been and so this will need careful review and monitoring.

Brexit impacts going forward

Availability of pharmaceuticals and implants is an area of uncertainty in the upcoming Brexit period, and with trauma and orthopaedic surgeons relying on implants for many of the procedures we undertake, this could raise serious problems. This could affect theatre throughput and the ability of surgeons to offer the most appropriate surgery to the patients that present. The uncertainties around these issues could affect workforce morale, particularly if any significant problems occur.

In future it will be much less attractive for European surgeons to come to the UK, and while this may be made up for by numbers coming from non-EU countries, this isn’t certain. There is a potential danger of overall reduction in the workforce size as a result of these factors. This applies not just to surgeons but across the health professions, e.g nursing.

Sept 2020